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I. Some people, having completed the traditional forms of empty speculation – “What do you want to be when you grow up?”, “If you could bang any celebrity who would it be?” – turn to “What will you say as your last words?” Sounds like a valid question. You can go out with a wisecrack, like Oscar Wilde (“Either this wallpaper goes or I do”). Or with piety and humility, like Jesus (“Into thy hands, o Father, I commend my spirit.”) Or burning with defiance, like Karl Marx (“Last words are for fools who haven’t said enough.”) Well, this is an atheist/skeptic blog, so let me do my job of puncturing all your pleasant dreams. You’ll probably never become an astronaut. You’re not going to bang Emma Watson. And your last words will probably be something like “mmmrrrgggg graaaaaaaaaaaHAAACK!” I guess I always pictured dying as – unless you got hit by a truck or something – a bittersweet and strangely beautiful process. You’d grow older and weaker and gradually get some disease and feel your time was upon you. You’d be in a nice big bed at home with all your friends and family gathered around. You’d gradually feel the darkness closing in. You’d tell them all how much you loved them, there would be tears, you would say something witty or pious or defiant, and then you would close your eyes and drift away into a dreamless sleep. And I think this happens sometimes. For all I know, maybe it happens quite a lot. If it does, I never see these people. They very wisely stay far away from hospitals and the medical system in general. I see the other kind of people. If you are like the patients I see dying, then here is how you will go. You will grow old. When you were young, you would go to institutions and gradually gather letters after your name: BA, MD, PhD. Now that you are old, you do the same thing, but they are different institutions and different letters. Your doctors will introduce you to their colleagues as “Mary Smith, COPD, PVD, ESRD, IDDM”. With each set of letters comes another decrease in quality of life. At first these sacrifices will be minor. The COPD means you have to breathe from an oxygen tank you carry around wherever you go. The PVD will prevent you from walking more than a few feet at a time. The ESRD will require three hours dialysis in a hospital or outpatient dialysis center three times a week. The IDDM will require insulin shots after every meal. Not fun, but hardly inconsistent with a life worth living. Eventually these will add up beyond your ability to manage them on your own, and you will be sent off to a nursing home. This will seem like a reasonable enough idea, and sometimes it goes well. Other times it gives you freedom to develop a completely new set of morbidities totally unconstrained by what a person in any other situation could possibly be expected to survive. You will become bedridden, unable to walk or even to turn yourself over. You will become completely dependent on nurse assistants to intermittently shift your position to avoid pressure ulcers. When they inevitably slip up, your skin develops huge incurable sores that can sometimes erode all the way to the bone, and which are perpetually infected with foul-smelling bacteria. Your limbs will become practically vestigial organs, like the appendix, and when your vascular disease gets too bad, one or more will be amputated, sacrifices to save the host. Urinary and fecal continence disappear somewhere in the process, so you’re either connected to catheters or else spend a while every day lying in a puddle of your own wastes until the nurses can help you out. The digestive system isn’t too happy either by this point, so you can either have a tube plugged directly into your stomach or just skip the middleman and have an IV line feeding nutrients into your bloodstream. Somewhere in the process your mind very quietly and without fanfare gives up the ghost. It starts with forgetting a couple of little things, and progresses until you have no idea what’s going on ever. In medical jargon, healthy people are “alert and oriented x 3″, which means oriented to person (you know your name), oriented to time (you know what day/month/year it is), and oriented to place (you know you’re in a hospital). My patients who have the sorts of issues I mentioned in the last paragraph are generally alert and oriented x0. They don’t remember their own names, they don’t know where they are or what they’re doing there, and they think it’s the 1930s or the 1950s or don’t even have a concept of years at all. When you’re alert and oriented x0, the world becomes this terrifying place where you are stuck in some kind of bed and can’t move and people are sticking you with very large needles and forcing tubes down your throat and you have no idea why or what’s going on. So of course you start screaming and trying to attack people and trying to pull the tubes and IV lines out. Every morning when I come in to work I have to check the nurses’ notes for what happened the previous night, and every morning a couple of my patients have tried to pull all of their tubes and lines out. If it’s especially bad they try to attack the staff, and although the extremely elderly are really bad at attacking people this is nevertheless Unacceptable Behavior and they have to be restrained ie tied down to the bed. A presumably more humane alternative sometimes used instead or in addition is to just drug you up on all of those old-timey psychiatric medications that actual psychiatrists don’t use anymore because of their bad reputation. After a while of this, your doctors will call a meeting with your family and very gingerly raise the possibility of going to “comfort care only”, which means they disconnect the machines and stop the treatments and put you on painkillers so that you die peacefully. Your family will start yelling at the doctors, asking how the hell these quacks were ever allowed to practice when for God’s sake they’re trying to kill off Grandma just so they can avoid doing a tiny bit of work. They will demand the doctors find some kind of complicated surgery that will fix all your problems, add on new pills to the thirteen you’re already being force-fed every day, call in the most expensive consultants from Europe, figure out some extraordinary effort that can keep you living another few days. (then these people will go home and log onto the Internet and yell at cryonics advocates for being selfish for wanting to live longer. Don’t those stupid cryonicists realize all that money could be spent on charity, instead of chasing after fantastically unlikely chances?)